Provider Demographics
NPI:1306355722
Name:WATT, JACQUELINE ALYSE (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:ALYSE
Last Name:WATT
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1664 N VIRGINIA ST # MS 152
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89557-0001
Mailing Address - Country:US
Mailing Address - Phone:775-784-4887
Mailing Address - Fax:775-784-8095
Practice Address - Street 1:1664 N VIRGINIA ST # MS 0152
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89557-2426
Practice Address - Country:US
Practice Address - Phone:775-784-4887
Practice Address - Fax:775-784-4095
Is Sole Proprietor?:No
Enumeration Date:2017-09-28
Last Update Date:2020-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR15408235Z00000X
NVSP-2674235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist